Escaping from Anorexia, Part II

I am often asked how it's possible to make the transition from knowing that anorexia is ruining one's life to actually saying no to it, and starting to eat more. I wrote some thoughts on this issue in my post on ‘What makes it possible to recover fully from anorexia?', but they were more about the question of how a complete rather than partial recovery can be achieved, and less about the details of that critical moment at which one decides, or fails to decide, to eat something more than usual, and to do so again tomorrow, and the next day, and all the days thereafter till one is better. Of course, as regards the transition itself, I speak only from my own experience, but as regards the difficulty, I have many readers' comments and correspondence to draw on.

So I thought I'd try this time - in a wider-ranging sequel to my original post on 'Escaping from anorexia' - to address in detail the numerous barriers to taking the plunge, or the leap of faith, that is required to end the deathly anorexic routines and initiate life-giving ones, and how those barriers might be overcome. I'll do this in the form of questions which I've been asked - and which I used to ask myself - and the best answers I currently have to them.

(Update 2017: I've since written another post on the gap between insight and action, and how to bridge it, here.)

Q 1. Given how awful my ‘life' with anorexia is, why haven't I felt the magic click, the flick of the switch that will transform things and make me able to start eating? I'm searching for it, but I can't find it.

A. There is no magic switch to make eating possible; looking for it is mainly just a way of procrastinating. The reasons for changing accumulate gradually, until they become more or less incontrovertible. But in my case at least, there was no off-to-on switch that made eating more seem possible, just long days of thinking, long hours of talking to friends, much uncertainty and fear, and finally the moment of actually eating. This is the only moment at which a switch may really click in your brain and body: once you've done the worst thing you, as someone with anorexia, can imagine, and eaten the extra chocolate bar or whatever. And even then, recovery will not be easy. Although there may be moments which feel like great flashes of realisation, there will mostly be the gradual, undramatic, day-by-day progress that you have to keep in motion until finally one day you wake up and know that you no longer have an eating disorder.

Realising the ‘one foot in front of the other' - or rather, the ‘one bite after another' - nature of recovery can be frightening, but it can also be strangely liberating, and empowering. It is scary to realise that, just as with the smoker who waits for the perfect time to quit, waits for the desire for nicotine to fade, waits to wake up one morning no longer wanting a cigarette, there is no perfect moment, except the one that you yourself create, simply by virtue of having waited long enough, and being willing to wait no longer. This is real empowerment, not the unreal kind that starvation whispers of. There's no reason not to take that first step now: by making a plan to start eating 500kcal a day more from tomorrow morning, and then carrying it out.

Q 2. I've tried to recover before, and it hasn't worked; why should I have any confidence it'll be different this time?

A. You should not think of past unsuccessful attempts to escape from anorexia as failures, failures which mean you're doomed to yet more failure. Instead, think of them as learning processes, which make you all the more likely to succeed this time. Despite popular wisdom about early intervention being key, longer illness need not translate into reduced likelihood of full recovery; the reverse may be true. You've learned a great deal about which instinctive responses made eating difficult, what physical effects eating had in the short term, and which emotional upsets caused relapses. You may also have caught glimpses of things that rewarded your efforts: the possibility of eating with others, a little more energy for walking upstairs, a sense of life not being a complete dead end. You should feel strengthened by this hard-won knowledge rather than crippled by it, and consider it all as extra armour for your next attempt. Although no doubt the disappointment of ‘failure' will have been tempered by the anorexic relief, even pride, at remaining thin and starving, no one likes to fail repeatedly at something they set their mind to. You needn't ‘fail' again. All that you've learned will make the next stage - of really eating and drinking and gaining weight consistently, getting healthier and stronger consistently - easier.

Q 3. What can I do about the little voice in my head, or monster on my shoulder, that tells me, every time I think about eating, that to do so would be weak, and make me fat, and that the world is trying to trick me into abandoning starvation, the only thing that makes the worthwhile and gives my life meaning?

A. The simple answer is to ignore the voice completely, because you've recognised it for what it is: a symptom of the anorexia - in particular, of your malnourished state -, which will kill you if you let it. It is necessary, the first time, and every subsequent time, to eat regardless of that voice whispering about the ‘benefits' of not doing so. To make the ignoring easier, you have to have a plan that you are determined to stick to, knowing that the negative feelings and cognitive-emotional wobbles are absolutely inevitable. You must have ready - written down, if need be - from the outset a food plan that doesn't depend on mood to be carried out every single day. For the sake of early and mid recovery, you must, as far as possible, divest eating and food of its emotional significance, its status of being earned, deserved, of being perfect or imperfect, of mattering more than anything. Its emotional role can regrow later, when you're strong enough for it to become an enriching one. To begin with, though, you must just eat because you have decided to, because you have a list (mental or physical) of reasons why you have decided to, and because you know that all the cognitive resistance you experience is not a reason to stop, but in fact the primary proof of why you must keep going.

The other possible answer to how to deal with the fruitless dialogue is to challenge the voice that tells you to carry on starving: ask what he or she or it is actually saying about why you should, and use your reason to challenge each piece of pseudo-logic (for that is of course what it is). (See point number 2 of my blog entry on recovering fully for a little more detail.) Having said this, the serious cognitive work is best left until you have the mental energy to tackle it, which you don't at the very beginning.

Q 4. I don't know how much to eat, because I'm hungry all the time, or never hungry at meal times. I feel completely detached from my own body and its needs, so how am I meant to eat more without bingeing uncontrollably, or without feeling bloated and in pain after the smallest thing? Why should I eat when I don't feel hungry?

A. I remember very well how this becomes another addictive feeling: reducing your own body more and more to something powerless and controlled by you, or else terrifyingly powerful and always near-to-uncontrollable, but in any case not part of you. The problem is that this separation (though ordinary language use makes it hard to avoid) profoundly misrepresents reality, because you are your body, and if you continue to ignore its needs it will die, and you with it.

As for how much to eat, and when, and what: it may seem bleak, but you cannot, in the beginning, appeal to ‘normality' - anorexia has denied you that right, for some months at least, and the crucial thing to start with is to let your body (including your brain) know that food will keep coming when it needs it, and that it's therefore safe for your body to abandon its famine-survival tactics. So, as I said in Q1, an extra 500 calories a day should be added to a previous diet that maintained a constant weight (you'll need to add more calories again soon if your weight is currently dropping, but start with 500 anyway), and this needs to be eaten every single day on top of what you're eating now. If you eat this much more every single day, it will allow you to regain about a pound, or half a kilo, a week. The amount of extra nutrition needed to put on substantial amounts of weight is considerable - but this shouldn't be scary, but instead give you confidence to do things properly. Don't just add a biscuit or a banana here or there; make a proper plan aiming for real increases in weight, and stick to it.

Eating more, by whatever means possible, is the most important thing by far. But eating regularly, and frequently, is a valuable skill to relearn too - ideally three meals and three snacks every day, at regular intervals, going no more than two or three hours without food. As long as the eating itself is happening reliably, starting to practise this kind of routine really consistently will mean both that the hunger you feel isn't of an overwhelming sort that could easily flip over into nausea, and also that your body really will very quickly start to feel hungry at the right time: what bodies like best is routine, and as soon as your body has confidence again that it's allowed to start planning ahead, it will do so. It will start secreting stomach acids at just the right time to digest the food you give it with maximum efficiency, which is what gives us the feeling of hunger - and it will learn not to do so at non-meal-times.

You have to train your body to get hungry at the right times, and then it will. Wanting to eat only when you're hungry is a reasonable desire, but it's up to you, initially, to establish a routine such that those times of hunger come at socially convenient times - and this requires you initially to ignore instinct in favour of rules. It may seem counter-intuitive, given ignoring embodied instinct is what anorexia is all about, but listening to your hunger is a privilege and a pleasure that you have to win back. You've mistreated your body and ignored its appetites too comprehensively to expect a normal relationship with food to be possible instantly. But it is possible, with time, if you exercise some unshakeable resolve at this initial stage. The knowledge of finally making amends to a body that has been faithful to you through these dark times, a body which has done its best despite being mistreated, is poignantly important. The same is of course true of your brain, though it may be less obvious: it will have the energy and nutrients it needs to function at full capacity only once restricted resources are not being channelled primarily into physical survival - and that will feel wonderful too.

The basic point in all of this is: don't expect to be well as soon as you start recovery. Now is not forever; some things need doing ruthlessly now so that later can be different.

Q 5. The only way I can keep some sort of mental equilibrium and calm is by carrying on as I am; I can't stop thinking about food at all, or being overwhelmed by other things, if I try to change my routines even in the tiniest way.

A. This is one of anorexia's many tricks: remaining anorexic is the ‘comfort blanket' that is actually just smothering you - your character, your strength, your ability to exist in the world and think about more than food. It doesn't solve problems, but defers them till the point at which you become physically strong enough to confront them again - which you must do one day, or die, or stay like this until you do. What stability you have is in fact a balance on a knife edge: your whole body craves food, and you are denying it that, and the best manifestation of the resulting impasse is an uneasy stand-off between ‘body' and ‘mind' that may sometimes feel like calm. (I scare-quote 'body' and 'mind', and should do the same with 'you' and 'your body', because as I suggested above, of course there is no real separation: your brain needs nourishment to work, just as your muscles do, and your physical state dictates how you think and the emotions you feel.)

Of course throwing anorexia off is frightening: you'll feel cold, vulnerable, and lost without it. But this is all part of the trick: all the things that feel easier to deal with when you're starving (not that you're ever dealing with anything properly then, just minimally coping) may start to creep back and feel overwhelming once you're eating more again, because your superficially stable basis for life has gone.

You'll desperately miss the ‘hunger high' (though you may feel even hungrier than usual when you first start eating more), and you'll have got so used to what feels like functioning at an acceptable level that you won't believe there could be any pay-off: that you could be more than just subsisting. But what you'll be doing by eating more is bargaining the likelihood of temporarily thinking about food all the time, and temporarily being overwhelmed by the rest of life, against the possibility of attaining the state in which food matters no more than any other daily pleasure does, and in which you embrace life, overflow with energy, laughter, warmth, and agility, and look beautiful and glowing instead of just terribly hollowed out and brittle. To me that seems a bet worth taking.

Keeping things as stable as possible, by insisting on an undebatable routine from the very start, also helps to get through this first phase. If there's simply no doubt that you'll be eating a certain thing at a certain time, it isn't terribly interesting for your mind to dwell feverishly on.

But finally, don't be afraid to think as much as you want and need to about this situation you are in. The belief that ‘the more you dwell on something, the more you give it credence' is a problematic one when it comes to mental illness, since aimless preoccupation can be detrimental, but cognitive effort aimed at the change of mental patterns is essential for recovery. And of course, when a life-changing decision is being made, it would be stupid not to be thinking about it a lot of the time. Building up the will to change requires time and patience and thought, and as long as this isn't only fretting about portion size and the possibility of getting obese, it may be no bad thing.

Q 6. What's to stop me becoming obese?

A. How likely is this, really? Why, given that you've been skeletally thin for some time, would there be any real reason to assume you'll ever have a problem with getting really fat? Much more likely a problem is that you'll struggle for a long time to gain enough weight to be healthy, and that is your primary aim. For now, there's no point in inventing implausible scenarios about the future, to increase your anxiety pointlessly. If there ever emerges any real danger of becoming obese, you can deal with it when it happens: you have all the skills necessary to deal with it efficiently, after all. The most likely course of events is that any weight gain will induce the urge to restrict, meaning you're miles away from being even a healthy weight, let alone slightly 'overweight' (as I was for a little while at the end of the weight-gain process), let alone clinically obese. Focus on the present, for now, and the grand present challenge of reaching a weight that can sustain life.

Q 7. I can't bear the idea of not being thinner than everyone else.

A. Comparisons with other people are terribly hard to avoid, but the sting can be taken out of them if you try to widen the scope of those comparisons by choosing a part of the body of the other person that isn't weight-related - their hair, or their feet, or something. This helps to diffuse the narrow focus on tummy, hips, bum, etc., which makes comparisons with others so dangerous for someone recovering from an eating disorder. Plus, you know what it costs you to be this thin, and at some point you will come to the conclusion that the cost isn't worth the ‘reward', if you haven't already. You might like to be envied by others for your thinness, but envy is an ugly emotion, and if you want to be envied, wouldn't it be better to be envied for something meaningful, some true achievement or quality, rather than for a sickness you haven't yet found a way out of, which has given you only a sterile ability not to eat enough? You will be more beautiful if your body is strong rather than crippled, and if you're happy rather than frightened, confused, and trapped.

Thinness by itself means absolutely nothing at all. It's perhaps worth mentioning that very few men find thin women attractive - they're evolutionarily inclined to like the fertile curves of healthy women - and that it's mostly women who engage in these ‘thinner is better' competitions amongst each other. For what? And now you know how stupidly easy it is to starve, how about trying something more interesting? How about declaring to the world that you've seen through the emptiness of the cult of thinness, and know that other aesthetics are more truly beautiful? How about seeking to impress, if you want to impress, through things that matter: kindness, lovingness, a sense of humour, loyalty, patience?

Q 8. I think I'm an essentially awful person who doesn't deserve to be healthy.

A. This is your illness, your malnutrition, speaking. If anyone on Earth deserves to eat enough to be healthy, you do too. (Arguably the whole notion of deserving is misplaced here, though.) Most of the things you probably hate yourself for - your selfishness, your intransigence, your short temper, your obsessiveness - are a direct consequence of your being so thin. Therefore the only way to become a less ‘awful person' is to eat more. If you don't deserve to, if even contemplating recovery can seem like an unwarranted self-indulgence, you must just remind yourself that you are probably an essentially good and kind person, but that this person has been submerged by starvation.

The only way to find out for sure is to grant yourself - the weak and uniform creature who is currently yourself - enough food to test this working hypothesis. If your low self-esteem still seems insurmountable, ask yourself in what way battling a potentially fatal mental illness, which is also having a potentially devastating effect on your family and friends, could possibly be considered self-indulgent? Would not the greatest imaginable selfishness be to evade the necessity of putting all your effort into this recovery by misdirecting your energies into other things that seem more ‘selfless', to the exclusion of eating and recovering? Nothing could be more selfish than continuing to starve yourself while those who love you look on, helpless. Don't beat yourself up for having succumbed to these things in the past - you never meant to hurt anyone - but seize this chance to put right the damage and see for yourself how ‘worthy' of health you can be if you let yourself.

And even if you have committed some great moral crime in the past, how is making yourself sick a truly virtuous response? Self-punishment is the easy option next to self-rehabilitation and the moral amends that can made through living a meaningful life in future.

Q 9. I'm afraid of my family and friends seeing me eating, and, if I manage it, seeming to find it easy; then they'll think I've just been pretending all along to be ill.

A. In the early years when my family was helping, or forcing, me to eat, I felt deeply conflicted, wanting to do what I knew made sense, but also feeling that I really ought to show how hard eating was for me, because otherwise people wouldn't believe anything was really wrong, or that recovery was really difficult - which I needed them to know. Struggling, and being seen to struggle, was a cry for help of sorts, I suppose, and a defence against the sort of mindset that asks, pragmatically, why I can't just eat, as everyone else manages to. However, by now your appearance and the narrowness to which your life has shrunk will probably have proven to everyone how seriously ill you are; the fuss which may have been made will have confirmed it; and you have nothing left to prove. It's clear to yourself and everyone else that you know how to starve yourself, and the challenge now is to show yourself (and them) that you can eat again.

You should also be grateful that you have the freedom - at least this time - of trying to do this on your own, on your own terms, rather than within the confines of the hospital ward, with all control taken from you (which is not necessarily a bad thing, but which doesn't prepare you very well for taking up the reins of normal life again afterwards). This is your chance to do your very best to prove right those who hope and believe you can do it thus, and to prove wrong those who doubt you, or believe only in your illness. Those who believe in you don't think you've been faking; they don't understand how anyone could wilfully reduce their life to this miserable minimum of survival, and therefore they know that you are desperately ill. You don't have to stay that way. It's OK to be ill, and then to stop being. The reality and legitimacy of your illness is not negated by a successful recovery: the extent of your illness will become clearest to you, and perhaps even to others, who see more clearly than you, only when you're better, and become a full human being again.

Let other people know what you plan to do, and let them help you. They will do all they can to help, if you tell them what they can do; they're longing to know of something that will help.

Q 10. I don't believe eating more will really change anything; this is how I am, why would eating a bit more make me any different? And even if it does, I'm scared of what I'll be without my anorexic identity, scared of where I'll end up.

A. Bodyweight is a very conspicuous marker of lifestyle and, by extension, in some senses of character. It's become very easy to vilify what is currently undesirable (fat), and invest its opposite with all the insidious ideals of strength, self-control, purity, etc. that really have very little to do with eating or not eating. Anorexia internalises all these illusory frameworks of value, so that your body shape and weight and your diet become symbols to you of everything you are and all you cherish. Dismantling this edifice of meaning is a terrifying process: it requires that everything you thought you believed in be rejected. But anyone who has been underweight for a while knows the essential hollowness of the argument that thinness gives you an identity - it doesn't. Nor do the meticulous routines of anorexic life: solitary, work- and food-orientated, infinitely repeated. These things make you just like every other person with anorexia: sick, unhappy, cold, hungry, and killing yourself slowly.

The question of what your ‘self' consists of, if not all the habits of thought and behaviour of present illness and an ever-extending past illness, is a frightening one, when you're in the midst of trying to alter those seemingly fundamental things. But it becomes less fraught when you realise that some things persist even while others drop away, and that your identity as (say) ‘Emily' may be a fiction (‘Emily' may be all sorts of different things at different times), but that in recovery and health this idea of identity can be mutable and multifaceted rather than monolithic.

No, you have no idea who you are or who you may become, but you know very well what anorexia has overlaid your identity with, and you know you're tired of all those unchanging, unremarkable character traits that don't add up to a character. Who knows what will emerge - but most likely lots of quiet little things which don't surprise you much at all: how much more you laugh, how great a pleasure the silliest things can be, how much less food matters, how much richer your voice sounds. Those sorts of things aren't so much frightening as simply delightful small surprises. There are other things more difficult to cope with: like increased emotional sensitivity, the feeling of losing control of various aspects of life (though of course the original control was an illusion), or the need to find new ways of existing, spending time, now so much of the restricting apparatus of illness has fallen away. But there's unlikely to be anything that, with bravery and acceptance, can't be embraced as exciting and revelatory. All this is about growing up (whatever your calendar age), and engaging with the world you're part of - something that anorexia defers or undoes, and which is always scary, but teaches you a great deal about yourself, and makes life infinitely broader, deeper, and richer.

Ultimately, you know exactly what anorexia has made of you, and although you may not believe that you ever were or could be anything else, no one who has enough to eat is as you are or behaves as you do. You probably hate other people with anorexia, if you know any, and that isn't because they're awful people, it's because they're ill, and defined by their illness, which is the same as yours. This is uncomfortable, but speaks compellingly to the question of whether eating more will change you, and whether it will do so in a positive way.

Q 11. I can theorise everything, decide that eating more makes sense, but am somehow paralysed when it comes to making that final act: just putting something extra to my lips and ingesting it. How can I overcome that paralysis?

A. You know all the reasons for eating by now. You know that at your current low weight, your thinking is highly determined by your starved state, so much so that you cannot really conceive of life being otherwise. Because no complete grasp of anorexia is possible while still in its grip, you must make your cognitive task simpler. You have (probably ad nauseam) all the objective evidence that things will change if you eat more, so you must decide to grant that evidence credence, and then set the decision to eat behind you as already made.

Reduce what is at stake here to the simple single fact of the need to keep eating and gaining weight, and reduce that to each simple single act of raising food to your mouth and eating it. By doing this, you can create a future for yourself which involves being and doing more than the symptoms and side-effects of anorexia. At this stage you can, more or less, stop thinking. Don't worry about the minute details of what brand of breakfast cereal or how much fruit and veg you're getting; simply choose things that you can best face eating, and that will meet your (now increased) daily calorie needs. All you have to do for now is make a simple and concrete eating plan - a set of rules, if you like, but the good sort. Then stick to these rules - even unthinkingly, even cynically, even fearfully. Include amongst your new rules and a clear contingency plan for what will happen if you break them, by failing to eat something you planned (not despairing, not self-flagellating, not abandoning the whole thing, just getting back on track as soon as possible). When it gets difficult, as it will, do as your contingency plan says: basically, eat again next time as planned. But also try imagining a happier, anorexia-free future: imagine a family barbecue in which you hang around happily eating burgers and drinking wine with everyone and that not being weird or a problem; imagine having a sexy healthy body and sharing it with someone; imagine people not looking at you in the street with thinly veiled pity.

This is the most meaningful investment in the future that you will ever make, and it will repay every ounce of effort a hundredfold. In the medium term, too, it will be a far better backdrop to getting on with work and other activities than carrying on starving, but it requires real work to get it set up firmly at the start. Get your plan written down, get the food bought (by someone else, if need be), get those doubts relegated to a place where, however much they plague you, they won't affect your actions of eating, and keeping eating as planned. Then sit down with that new food you've bought, and enjoy it.

Let your starved body enjoy it, and perhaps briefly flounder in unfamiliarity. Let your mind marvel at the weirdness, the novel taste; let it experience its own terror but know that each mouthful will lessen the terror. Let the years you have left in this world not be squandered in the cold and hunger and fear of anorexia. Let eating bring you back to life. Right now is the best time to make that start happening.

With thanks to my partner, David Mossop, for all his insightful improvements to this post.